Deanol in the treatment of tardive dyskinesia

Determination of urinary deanol-N-oxide excretion profiles after ingestion of nutritional supplements containing deanol

2-(Dimethylamino)ethan-1-ol (Deanol) is a widely produced chemical used by both industry and consumers in a variety of applications. Meclofenoxate, a stimulant classified on the World Anti-Doping Agency Prohibited List, metabolizes into deanol and, presumably, its main metabolite deanol-N-oxide. Hence, using liquid chromatography-tandem mass spectrometry, a quantitative detection method for deanol-N-oxide in urine was developed. Subsequently, the urinary excretion of deanol-N-oxide after oral application of 130 mg of deanol was determined in six volunteers, and urine samples of a cohort of 180 male and female athletes from different sports were analyzed. In addition, urinary deanol-N-oxide was determined in an exploratory study with one volunteer ingesting 250 mg of meclofenoxate. The developed test method allowed for limits of detection and quantification for deanol-N-oxide at 0.05 and 0.15 μg/mL, respectively. Urinary deanol-N-oxide cmax levels were found between 100 and 250 μg/mL 2-5 h post-administration of 130 mg of deanol. Similarly, urine samples collected after the administration of 250 mg of meclofenoxate exhibited cmax levels of 115 μg/mL. In contrast, deanol-N-oxide urine concentrations of pre-administration specimens and 180 routine doping control urine sample were between 0.3 and 1.3 μg/mL and below limit of quantification and 1.8 μg/mL, respectively. The study suggests that the use of deanol and meclofenoxate results in significantly elevated urinary deanol-N-oxide levels. Whether or not monitoring deanol-N-oxide in doping controls can support decision-making processes concerning the detection of meclofenoxate use necessitates further investigations taking into consideration the elimination kinetics of 4-chlorophenoxyacetic acid, the main metabolite of meclofenoxate, and deanol-N-oxide.

What is the evidence on cholinergic medication for tardive dyskinesia?

Antipsychotic drugs are associated with movement disorders, especially with long-term use. Tardive dyskinesia, a condition characterised by repetitive involuntary muscle activity, is considered to be the most chronic, distressing and disabling of antipsychotic-associated movement disorders. There is theoretical justification for the use of cholinergic drugs in tardive dyskinesia, and they are used in clinical practice. A Cochrane systematic review synthesised randomised controlled trial data evaluating the effectiveness of cholinergic drugs for tardive dyskinesia, and for a range of secondary outcomes, including quality of life. In line with the authors of the review, this Commentary concludes that much higher-quality evidence on the use of cholinergic drugs in tardive dyskinesia is necessary, and that a patient with tardive dyskinesia should be offered the opportunity to try a newer cholinergic drug, ideally in the context of a well-conducted and reported clinical trial. At the same time, given uncertainty regarding clinical effectiveness, and in view of their accepted adverse effects, it would be understandable if a person with tardive dyskinesia decided to avoid cholinergic drugs.

DECLARATION OF INTEREST

None.

Cholinergic medication for antipsychotic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) remains a troublesome adverse effect of conventional antipsychotic (neuroleptic) medication. It has been proposed that TD could have a component of central cholinergic deficiency. Cholinergic drugs have been used to treat TD.

OBJECTIVES

To determine the effects of cholinergic drugs (arecoline, choline, deanol, lecithin, meclofenoxate, physostigmine, RS 86, tacrine, metoxytacrine, galantamine, ipidacrine, donepezil, rivastigmine, eptastigmine, metrifonate, xanomeline, cevimeline) for treating antipsychotic-induced TD in people with schizophrenia or other chronic mental illness.

SEARCH METHODS

An electronic search of the Cochrane Schizophrenia Group's Study-Based Register of Trials (16 July 2015 and April 2017) was undertaken. This register is assembled by extensive searches for randomised controlled trials in many electronic databases, registers of trials, conference proceedings and dissertations. References of all identified studies were searched for further trial citations.

SELECTION CRITERIA

We included reports identified by the search if they were of controlled trials involving people with antipsychotic-induced TD and chronic mental illness, who had been randomly allocated to either a cholinergic agent or to a placebo or no intervention. Two review authors independently assessed the methodological quality of the trials.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and, where possible, estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We analysed data on an intention-to-treat basis, with the assumption that people who left early had no improvement. We assessed risk of bias and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

We included 14 studies investigating the use of cholinergic drugs compared with placebo published between 1976 and 2014. All studies involved small numbers of participants (five to 60 people). Three studies that investigated the new cholinergic Alzheimer drugs for the treatment of TD are new to this update. Overall, the risk of bias in the included studies was unclear, mainly due to poor reporting; allocation concealment was not described, generation of the sequence was not explicit, studies were not clearly blinded, we are unsure if data are incomplete, and data were often poorly or selectively reported.We are uncertain about the effect of new or old cholinergic drugs on no clinically important improvement in TD symptoms when compared with placebo; the quality of evidence was very low (RR 0.89, 95% CI 0.65 to 1.23; 27 people, 4 RCTs). Eight trials found that cholinergic drugs may make little or no difference to deterioration of TD symptoms (low-quality evidence, RR 1.11, 95% CI 0.55 to 2.24; 147 people). Again, due to very low-quality evidence, we are uncertain about the effects on mental state (RR 0.50, 95% CI 0.10 to 2.61; 77 people, 5 RCTs), adverse events (RR 0.56, 95% CI 0.15 to 2.14; 106 people, 4 RCTs), and leaving the study early (RR 1.09,95% CI 0.56 to 2.10; 288 people 12 RCTs). No study reported on social confidence, social inclusion, social networks, or personalised quality of life.

AUTHORS' CONCLUSIONS

TD remains a major public health problem. The clinical effects of both older cholinergic drugs and new cholinergic agents, now used for treating Alzheimer's disease, are unclear, as too few, too small studies leave many questions unanswered. Cholinergic drugs should remain of interest to researchers and currently have little place in routine clinical work. However, with the advent of new cholinergic agents now used for treating Alzheimer's disease, scope exists for more informative trials. If these new cholinergic agents are to be investigated for treating people with TD, their effects should be demonstrated in large well-designed, conducted and reported randomised trials.

Systematic review of cholinergic drugs for neuroleptic-induced tardive dyskinesia: a meta-analysis of randomized controlled trials

The authors evaluated the efficacy of cholinergic drugs in the treatment of neuroleptic-induced tardive dyskinesia (TD) by a systematic review of the literature on the following agents: choline, lecithin, physostigmine, tacrine, 7-methoxyacridine, ipidacrine, galantamine, donepezil, rivastigmine, eptastigmine, metrifonate, arecoline, RS 86, xanomeline, cevimeline, deanol, and meclofenoxate. All relevant randomized controlled trials, without any language or year limitations, were obtained from the Cochrane Schizophrenia Group's Register of Trials. Trials were classified according to their methodological quality. For binary and continuous data, relative risks (RR) and weighted or standardized mean differences (SMD) were calculated, respectively. Eleven trials with a total of 261 randomized patients were included in the meta-analysis. Cholinergic drugs showed a minor trend for improvement of tardive dyskinesia symptoms, but results were not statistically significant (RR 0.84, 95% confidence interval (CI) 0.68 to 1.04, p=0.11). Despite an extensive search of the literature, eligible data for the meta-analysis were few and no results reached statistical significance. In conclusion, we found no evidence to support administration of the old cholinergic agents lecithin, deanol, and meclofenoxate to patients with tardive dyskinesia. In addition, two trials were found on novel cholinergic Alzheimer drugs in tardive dyskinesia, one of which was ongoing. Further investigation of the clinical effects of novel cholinergic agents in tardive dyskinesia is warranted.

Cholinergic medication for neuroleptic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia remains a troublesome adverse effect of conventional antipsychotic (neuroleptic) medication. It has been proposed that tardive dyskinesia could have a component of central cholinergic deficiency. Cholinergic drugs have been used to treat tardive dyskinesia.

OBJECTIVES

To determine the effects of cholinergic drugs (arecoline, choline, deanol, lecithin, meclofenoxate, physostigmine, RS 86, tacrine, metoxytacrine, galantamine, ipidacrine, donepezil, rivastigmine, eptastigmine, metrifonate, xanomeline, cevimeline) for treating neuroleptic-induced tardive dyskinesia in people with schizophrenia or other chronic mental illness.

SEARCH STRATEGY

An electronic search of the Cochrane Schizophrenia Group's register (October 2001) was undertaken. This register is assembled by extensive searches for randomised controlled trials in many electronic databases, registers of conference proceedings and dissertations. References of all identified studies were searched for further trial citations. Principal authors of trials were contacted.

SELECTION CRITERIA

Reports identified by the search were included if they were of controlled trials dealing with people with neuroleptic-induced tardive dyskinesia and chronic mental illness, who had been randomly allocated to either a cholinergic agent or to a placebo or no intervention. Two reviewers independently assessed methodological quality of trials.

DATA COLLECTION AND ANALYSIS

Two researchers extracted data and, where possible, estimated relative risks (RR) or weighted mean differences (WMD), with 95% confidence intervals (CI). Data were analysed on an intention-to-treat basis, with the assumption that people who dropped out had no improvement.

MAIN RESULTS

We included eleven studies investigating the use of older cholinergic drugs compared with placebo. Most studies involved small numbers of participants (5-20 people). We found no completed trials of the new cholinergic Alzheimer drugs for the treatment of tardive dyskinesia. Cholinergic drugs did not result in any substantial improvement in tardive dyskinesia symptoms when compared with placebo (8 RCTs, 170 people, RR no important improvement 0.84 CI 0.68 to 1.04). Neither did tardive dyskinesia symptoms increase (7 RCTs, 137 people, RR deterioration in tardive dyskinesia 1.17 CI 0.55 to 2.50). Pooled results for endpoint AIMS scores were equivocal (4 RCTs, 86 people, WMD -0.19 CI -0.53 to 0.14). Deanol may cause gastric adverse effects (5 RCTs, 61 people, RR 9.00 CI 0.55-148) and other adverse effects such as sedation and peripheral cholinergic effects (6 RCTs, 94 people, RR 6.83 CI 0.99-47). One study reported on global outcome. Meclofenoxate was neither clearly helpful nor harmful when compared with placebo (1 RCT, 60 people, RR not of global benefit 0.89 CI 0.59 to 1.32). We found no difference between people allocated cholinergics and those given placebo for the outcome of leaving the study before completion (10 RCTs, 240 people, RR 0.52 CI 0.21 to 1.33).

REVIEWER'S CONCLUSIONS

Tardive dyskinesia remains a major public health problem. The clinical effects of older cholinergic drugs are unclear, as too few, too small studies leave many questions unanswered. Cholinergic drugs should remain of interest to researchers and currently have little place in routine clinical work. However, with the advent of new cholinergic agents now used for treating Alzheimer's disease, scope exists for more informative trials. If these new cholinergic agents are to be investigated for treating people with tardive dyskinesia, their effects should be demonstrated in well-designed, conducted and reported randomised trials.

Antipsychotic agents: a clinical update

Antipsychotic agents have many indications and are frequently used. All physicians, regardless of their subspecialty, will most likely treat patients who receive these drugs. This article is designed to help nonpsychiatric physicians use antipsychotics appropriately. The indications, recommended dosages, side effects, and drug interactions of antipsychotic medications are reviewed. Receptor binding data are used to help predict the side-effect profile of these agents. Knowledge of these side effects and of the patient's medical condition helps the physician select a drug that the patient can tolerate. Management of overdose situations is discussed.

A comparison of purposeless movements in psychiatric patients treated with antipsychotic drugs, and normal individuals

Oro-facial dyskinesia and purposeless trunk and limb movements were assessed, using a standard videotape rating technique, in 182 psychiatric patients receiving antipsychotic medication, in a second sample of 43 elderly psychiatric patients also receiving antipsychotic drugs, and 85 normal, drug-naive subjects. In both the first patient sample and the group of normal subjects, oro-facial dyskinesia was more common over 50 years of age. Statistical analysis of the data suggested that drug-induced oro-facial dyskinesia has a characteristic pattern of movement distribution significantly different from that of idiopathic oro-facial dyskinesia. The videotapes of the first patient sample and the normal subjects were viewed by a neurologist who assessed and categorised all movements. Purposeless trunk and limb movements were classified as either normal or abnormal. Normal purposeless movements were significantly more common in the drug-naive subjects. The presence of abnormal movements such as choreiform movements, dystonias and stereotypies and mannerisms was limited, almost exclusively, to the patients.

Behavioral effects of deanol, of hemicholinium and of their interaction

The present experiments were designed to study behavioral effects of two chemicals, which have opposite influences on the cholinergic neurotransmitter system, and of their interaction. It has been proposed that deanol is a direct precursor of acetylcholine (ACh) in brain and may enhance cholinergic transmission, while hemicholinium-3 (HC-3) acts to decrease ACh synthesis. Rats served as subjects. Doses of the drugs were based on results of earlier experiments; all were injected cerebroventricularly. The six treatment groups were: saline only; HC-3 (10 micrograms); HC-3 (10 micrograms) + deanol (1 microgram); HC-3 (10 micrograms) + deanol (10 micrograms); deanol (1 microgram); and deanol (10 micrograms). Behaviors measured were: reactivity to visual and tactile stimuli; resistance to capture and handling, vocalization, muscular tension; reactivity to non-contingent aversive stimulation; and, shock-induced defence reaction. With the exception of the defence reaction, all behaviors showed significant effects between the various drug treatments: deanol had no significant effect on the behaviors; animals receiving HC-3 only clearly showed responses which were enhanced above the levels of any of the other treatment groups; deanol had a dose-dependent effect of suppressing HC-3 enhanced behavior. The present results are consistent with the generalization that decreased cholinergic activity is associated with hyper-reactivity, and increased cholinergic activity with hyporeactivity. They indicate that the behavioral effects of deanol are dependent upon the state of the cholinergic system, interacting in combination with HC-3 but not alone.

Pharmacotherapeutic trials in tardive dyskinesia

Some of the clinical factors contributing to the currently unsatisfactory state of therapy for tardive dyskinesia are reviewed. Problems such as lack of clear syndrome delineation and phenomenological description, the lack of standardization in rating scales and the lack of attention to trial design have all probably contributed to a rather confusing picture. Controlled trials suggest that several pharmacological agents may be of therapeutic value but that clinical prediction of an individual's response is impossible. The strategy of acute drug challenge has emerged as perhaps the most promising approach to the definition of pharmacological subtypes and therefore the choice of optimal treatment.

Ineffectiveness of deanol in tardive dyskinesia: a placebo controlled study

In a double-blind placebo-controlled study, deanol acetamidobenzoate, administered in doses up to 1.5 g q.d. for three weeks to chronic schizophrenic patients presenting moderate to severe tardive dyskinesia, failed to alleviate the dyskinetic movements. However, there was a tendency for a significant increase in the schizophrenic symptoms of the deanol-treated group relative to the control group. The ineffectiveness of deanol in alleviating tardive dyskinesia is consistent with its inability to enhance brain acetylcholine synthesis. The worsening of the schizophrenic symptoms may possibly result from an interference by deanol with central cholinergic function.

A rating scale for tardive dyskinesia

A rating scale for tardive dyskinesia was developed, consisting of nearly all signs seen by two groups of investigators over a 5-year period. Thirty-four items were included in the scale with a possibility of writing in idiosyncratic signs. The scale was shown to have good reliability and validity in studies carried out by both the New York and Boston groups. It is recommended as a suitable instrument for describing the breadth of tardive dyskinesia syndrome and also for quantifying the disorder. A second scale, "the abbreviated dyskinesia scale", contains 13 items which are more global than the items in the original scale. It also has been shown to be both reliable and valid. Its use is suited to situations requiring less extensively detailed assessments.

Dimethylaminoethanol (deanol): effect on apomorphine-induced stereotypy and an animal model of tardive dyskinesia

Dimethylaminoethanol (DMAE) was administered acutely to rats subsequently injected with spomorphine. A dose of 80 mg of DMAE had no effect on the severity of apomorphine-induced stereotypy. However, 160 mg of DMAE significantly diminished the severity of apomorphine-induced stereotypy. This dose of DMAE did not significantly alter spontaneous locomotor activity. DMAE did not reduced apomorphine-induced stereotypy in animals previously exposed to haloperidol and presumed to have postsynaptic dopamine receptor supersensitivity. These results with DMAE are contrasted with the effects of choline chloride, and suggest that choline chloride may be more effective than DMAE at augmenting striatal cholinergic activity.